Health care in rural areas

In India, although the health care system infrastructure is extensive, the people often regard government facilities as family planning (FP) centers instead of primary health care centers. This problem has been compounded by the separation of health care and FP at all stages, even down to the storage of the same medication in two different locations depending upon whether it is to be used for "health" or for "FP." In rural areas where the government centers are particularly desolate, the community has chosen to erect its own health care system of private practitioners of all sorts and qualifications. Even in rural areas where a comprehensive health service is provided, with each household visited regularly by health workers, and where this service has resulted in a lowering of the crude death rate from 14.6 to 7 and the maternal mortality rate from 4.7 to 0.5/1000, people depend upon practitioners of various types. Upon analysis, it was discovered that the reason for using this multiplicity of practitioners had nothing to do with the level of satisfaction with the government service or with the accessibility of the services. Rather, when ill, the people make a diagnosis and then go to the proper place for treatment. If, for instance, they believe their malady was caused by the evil eye, they consult a magico-religious practitioner. These various types of practitioners flourish in areas with the best primary health care because they fulfill a need not met by the primary health care staff. If government agencies work with the local practitioners and afford them the proper respect, their skills can be upgraded in selected areas and the whole community will benefit.     

The rural private practitioner

Recent research has revealed that the health care of India's rural population is being provided by private practitioners. With as many as 1,250,000 private practitioners providing health services to at least half of India's population, three studies were conducted to shed light on the profile and practice of the private practitioners. It was found that the private practitioners are almost always male, practice in or close to their birthplace, and have attended school. Only 25% are graduates, however, and almost 50% have no formal training. Regardless of training, nearly 90% practice allopathy. In a study of 542 patients, no physical examinations were conducted in 47% of the cases, but the patients were satisfied with the care they received because the private practitioners paid more attention to them than they were accustomed to receive from primary health care doctors. The private practitioners are compensated by adding a surcharge to the fee for medicines. The patients believe that they are simply purchasing medications. This system requires the practitioners to dispense medications, injections, or both to receive compensation. Medications, including antibiotics, are given in small doses (a practice which is certainly harmful). The practitioners refer difficult cases to the government centers. Most of the practitioner, however, practice alone, with their only professional contact being the town chemist. Almost all of these practitioners expressed interest in joining an association. Analysis of the cost of this health care shows that it accounts for a substantial portion of rural expenditure and constitutes a sizeable hidden "industry." In order to respond to this situation, the government must either ban the untrained rural private practitioner, promote the quality of care provided by the government network, or acknowledge the existence of the private practitioners and provide them with support and training.     

THE CONCEPT OF WELL-BEING IN A RURAL SETTING: UNDERSTANDING HEALTH AND ILLNESS

ABSTRACT: Attitudes to health and illness may differ between rural and urban dwellers. Issues that may relate to the provision of health services to rural dwellers are raised for consideration. The response of urban dwellers to illness or disability has often been linked to discomfort caused by pain or cosmetic attractiveness, while for rural dwellers the response to illness or disability is often related to the degree to which the illness or disability affects productivity. Often the rural resident will postpone seeking medical or associated services until it is economically or socially convenient. The notion of exposing their private lives to strangers or acquaintances from the local based services or to undertake the journey to distant services where the cultural or behavioural differences could be misunderstood, may impact on rural dwellers' well-being. Health service providers in rural areas need to understand such differences and difficulties when offering services.     

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.     

Health services reform in Poland: issues in recent developments

After ten years of debate and discussion, the political situation within Poland finally allows the possibility to implement basic reforms in the health care system. Parallel development of the political and technical aspects of the reform has now lead to a final proposal for fundamental reforms in health system responsibility, financing and management. This article describes the current conceptual developments and the political and social context for these final reform proposals at the time of their submission to the government. The primary changes suggested are aimed at increasing the awareness of local, regional and national administrations, health care professionals and the general public that health care has a cost, and that resources must be used carefully if they are to cover health needs. In addition, 'health care' as a term must be extended to include factors and activities besides direct medical services. Such factors as air and water quality, diet, smoking and alcohol consumptions are examples of matters which will also be included in the focus of health system planners. A key element of the organisational reforms is decentralisation of responsibility for health care planning and administration within the framework of nationally set standards and priorities. Based on local decisions, the current basic organisation unit of health care delivery, the ZOZ or integrated health care units, will be redefined and either decomposed into their component services or receive newly defined responsibilities more adapted to the local realities of available manpower and medical facilities. In addition, the development of a private health care sector complementing and even competing with the public services sector will be actively encouraged.     

Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics?

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as 'appropriate' or 'inappropriate'. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women. Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these 'inappropriate' facilities remained strong, graded and in the expected direction. Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, 'good' facilities should be given technical support and supplied with drugs and equipment.     

Barriers of mistrust: public and private health sectors' perceptions of each other in Madhya Pradesh, India

India has one of the most highly privatized health care systems in the world. The dominant private health sector functions alongside a traditional tiered public health sector. There has been an overall lack of collaboration between the two sectors despite international policy recommendations and local initiatives. It has been postulated that "conflicting perceptions" might contribute to the uncooperative attitude between the two sectors. But there has been little empirical exploration of the existing perceptions that the private and public health sectors have of each other. We explored these perceptions among key stakeholders (who influence the direction of health policy) in the public and private health sectors in the province of Madhya Pradesh, India. The barriers of mistrust, which hinder true dialogue, are complex, and have social, moral, and economic bases. They can be best addressed by necessary structural change before any significant long-term partnership between the two sectors is possible.     

Public expenditures and health care in Africa.

Unfavorable economic conditions in most of Africa (in this paper Africa refers to Sub-Saharan Africa only) have meant public austerity and a deceleration in government health spending. Given the dominant role of government in providing health services in Africa there is a need to investigate the links between public spending and the provision of health care. Analyzing information from five Sub-Saharan African countries, namely Botswana, Burkina Faso, Cameroon, Ethiopia and Senegal, we investigate the impacts of shifting expenditure patterns and levels on the process of providing health services as well as on delivery of health care. The country analyses indicate that in addition to the level of public spending, the expenditure mix (i.e. salaries, drugs, supplies etc.), the composition of the health infrastructure (hospitals, clinics, health posts etc.), community efforts, and the availability of private health care all influence health care delivery. Consequently, per capita public expenditure (the most important indicator in a number of related studies) alone as a measure of the availability of health care and especially for cross-country comparisons is inadequate. Reductions in government resources for health care often result in less efficient mixing of resources and hence less health care delivery, in quality and quantity terms. With the recent trends in health care spending in Africa there should be greater effort to increase the efficient use of these increasingly scarce resources, yet the trend in resource mix has been in the opposite direction. Given the input to public health care of local communities, as well as the provision of private health care, it would seem that government spending on health care should be counter-cyclical, i.e. government health spending should accelerate during periods of economic down turns. Such counter-cyclical spending would tend to offset the difficulties facing local communities and the declining ability of individuals to pay for private health care. Recommending counter-cyclical health spending may seem wishful, but it points up the necessity of understanding what is likely to happen to health care in African countries in the face of economic difficulties, and particularly in the face of fiscal austerity.     

Challenges to sanctuary: the clergy as a resource for mental health care in the community

The transfer of psychiatric care from the institution to the community has presented community structures including faith-based organisations (FBOs) with an additional burden of care. In recent years there has been an increasing policy interest among government departments, public and non-statutory agencies for the inclusion of FBOs as partners in health and welfare services. However, despite their long historical involvement in healing and healthcare, clergy are seldom viewed by mental health professionals as partners in healing and restitution but with suspicion [Koenig, 1988. Handbook of Religion and Mental Health San Diego: Academic Press; Larson, Hohmann, & Kessler, 1988. The couch and the cloth: The need for linkage. Hospital and Community Psychiatry, 39, 1064-1069]. This may be compounded by ignorance about mental health care provision within FBOs in the UK and the preparedness, confidence and willingness to undertake such care. This paper is based on a study which examined clergy contact with people with mental illness. Thirty-two interviews were conducted with male clergy (Christian ministers, rabbis, and imams) most of whom were London-based. We examine barriers and dilemmas for clergy in caring for people with mental illness. We found that they play an important but often confined role the scale and impact of which is not recognised by their central organisation and training bodies. Low confidence about managing psychiatric problems, underscored by anxiety, fear and stereotyped attitudes to mental illness restrain their willingness to formalise their function. We argue that any proposed extension of clergy involvement in mental health will require further research and thorough deliberation by mental health services and religious organisations.     

The poor pay more: Health-related inequality in Thailand

This paper examines the equality of utilization for equal need and equity of out-of-pocket expenditure for health services in a large urban area in Thailand. Data from a household health interview survey were used to explore patterns of perceived morbidity, utilization of various treatment sources, and out-of-pocket payment. Financial access to health care, as reflected in medical benefit/insurance cover, appeared to influence reported illness and hospitalization rates. Gross lack of access to health care amongst lower socio-economic groups was not the main problem in this densely populated urban area because people could choose and use alternative health services according to their ability and willingness to pay. The corollary, however, was an inequitable pattern of out-of-pocket health expenditure by income quintile and per capita. The underprivileged were more likely to pay out of their own pocket for their health problems, and to pay out of proportion to their household income when compared with more privileged groups. Furthermore, the underprivileged were least likely to be covered by government health benefit schemes, in contrast in particular to civil servants, who paid less out of pocket and did not contribute to their medical benefit fund. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Policy options for the short and long term to improve the equity of payment systems for health care are discussed.     

Oral health care services in Europe

Health care is being reformed in Europe. Comparative analyses of oral health care services are scarce. Little is known about the relationship between organisation and financing of services and the effectiveness, efficiency and equity of the services. The purpose of the paper is to present some features of the delivery of oral health care services and to discuss some recent changes in a public health perspective. Some of the recent changes in oral health care are: Decentralisation of management in the public services, less third party payment and higher patient charges, more emphasis on free consumer choice. The dominant model of delivery of oral health care is the single private practitioner. The traditional structure of delivery of dental services is challenged by the demands of societies. There seems to be a trade-off between simplicity and the tailor-made mixed payments: gains in degree of freedom through the use of mixed payment systems have to be balanced against losses in terms of simplicity of implementation and equality of the oral health outcome. The roles of the provider, the consumer and the financing institutions are imbedded in trust and regulation. There is therefore a growing recognition of the necessity for a strong role of public health.     

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

Background

After many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?

Methods

A 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq's 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.

Results

Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.

Conclusions

There is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.     

Using private health insurance. A study of lay decisions to seek professional medical help

This paper examines the decision making process associated with the use of private health insurance. In particular, it focusses on the criteria respondents draw on to decide when to use the private health sector and when not to. This is an important issue as it gives insight into how the use of the private sector relates to use of the National Health Service. It also informs the theoretical debate about help-seeking behaviour, in particular, the usefulness of the notion of choice and ‘shopping around’ in the health care market. It is concluded that users of health care do exhibit a reasoned approach in deciding between different medical care settings, although due to lack of knowledge and passivity in the patient role, the final decision is usually made by their general practitioner.     

Promoting critical thinking in health care: Phronesis and criticality

This paper explores the notion of ‘expert’ health care practitioner in the context of critical thinking and health care education where scientific rather than philosophical inquiry has been the dominant mode of thought. A number of factors have forced are appraisal in this respect: the challenge brought about by the identification of complex ethical issues in clinical situations; medicine's `solving' of many of the simple health problems; the recognition that uncertainty is a common and perhaps innate feature of clinical practice; debate about the concepts of illness and disease; plus insights from psychology,sociology and medical anthropology. Together these have prompted alternative ways of thinking which have the aim of identifying the best rather than the right decision (where best equates to good and right equates to correct in the sense of true or approved). It is argued that phronesis adds a necessary corrective dimension to modern Western medicine's over-emphasis on techne and is one of the factors that differentiates novice from expert practitioner. However, this attracts certain conflicts of interest: phronesis can only be gained and assessed from experience of praxis; agencies with legitimate interests in medicine such as government and professional registering bodies require more substantive criteria. This revised version was published online in July 2006 with corrections to the Cover Date.     

Using medical care: the views and experiences of high-risk mothers.

Two recurrent unsolved problems of health services practice and policy in modern industrial countries are those of social class inequalities and user dissatisfaction. This article presents data related to these issues drawn from a sample of British childbearing women deemed "at risk" by health professionals. A third focus is on the relationship between past experiences of maternity care, and the patterns of service provision and perceptions of needs and satisfaction revealed in a subsequent pregnancy. Findings show a tendency for patterns of care to be differentiated by social class, with working class women generally receiving comparatively poor service. Satisfaction with general practitioner (community-based) prenatal care is higher than with hospital care. The more socially disadvantaged women in the sample are more likely to be dissatisfied with their medical care. The three major pregnancy needs highlighted by the sample women are for more continuity of care, more sympathetic medical care, and help with household finances. Adverse previous childbearing experiences are related to more dissatisfaction in the subsequent pregnancy.     

Promoting the private sector: a review of developing country trends

Two questions are addressed in this article: (i) How can itbe ensured that private sector resources promote national healthgoals? and; (ii) What can be learnt from the private sectorto enhance operations in the public sector? There is a surprisingdegree of private sector activity in both the finai icing andprovision of services, despite the fact that few countries haveadopted wide-reaching privatization programmes. In some countriespressure upon government budgets for health has led to privatesector expansion - in others rapid income growth accompaniedby increased demand for health care is a causal factor. A number of problems related to private for-profit providersare evident; often quoted are supplier-induced demand and excessiveinvestment in high technology equipment, the equity implicationsof private health care, and the availability of manpower forthe public sector. Governments have tried to tackle these problemsthrough a range of innovative interventions, however littleproper evaluation of these policies has been carried out. Whilesuch problems are less likely to arise with the private, not-for-profitsector, the financial sustainability of their activities ismore worrying. There is also a need to define more clearly therelationships between governments and not-for-profit organizations. The paper considers market-oriented reforms in industrializedcountries, and their implications for the health sector in developingcountries. The measures taken in industrialized countries appearto be of limited direct applicability in developing countries,due to factors such as the sparse coverage of health facilitiesin the latter. However the principles on which the reforms arebased are relevant, in particular the need for greater transparencyin the activities of public and private sector providers andin the use of con tracting out services. Finally it is suggestedthat too much research in this area has focused on defendingone or other side of the privatization debate. Not enough workhas considered the health sector as a whole, and the complicatedinteractions between public and private sectors as providers,buyers, financ ing agents and regulators of health care services.     

Improper office disposal of needles and other sharps: an occupational hazard outside of health care institutions

An employee of a private disposal company suffered a finger needlestick injury while collecting waste at curbside from a building containing medical offices. Subsequent inspection of the contents of the garbage bags revealed the presence of used syringes and unsheathed needles. The Ministry of the Environment has developed a regulation and guidelines for the handling and disposal of biomedical waste including needles and other sharps. These specify that approved carriers and receivers are required for disposal; properly decontaminated waste is considered non-hazardous solid waste and can go to landfills. However, responsibility for curbside pickup of waste lies with municipalities; some municipalities have enacted by-laws which prohibit collection of this waste at the curbside. This incident illustrates that improper disposal of biomedical waste (including that from private practitioners' offices) may occur despite efforts to control its handling, and that needlestick injuries can occur outside of health care facilities among personnel who are not health care workers. Efforts are needed to increase the level of awareness among health professionals regarding their responsibility to ensure proper biomedical waste disposal from private offices. In addition, efforts should be made to bridge the gap between all levels of government regarding the disposal of biomedical waste.     

Financing nutrition services in a competitive market

Budget deficits and inflationary medical care costs threaten nutrition services, which until recently have been funded largely by federal, state, and local revenues. Nutritionists and dietitians responding to demands in the marketplace should develop innovative programs and pursue new sources for financing through the private sector, third-party payers, business/industry health promotion, and consumer fees for their services, as well as targeted federal, state, and locally funded food assistance, nutrition education, and health care programs. Trail-blazing dietitians are successfully offering their services in health maintenance organizations (HMOs), hospital or industry fitness programs, private practice, voluntary health agencies, and official agency programs. With the new federalism, nutritionists must articulate their role in comprehensive health care and market their services at the state and local levels in addition to the federal level. Nutrition services are defined to include assessment, planning, counseling, education, and referral to supportive agencies. Data management, managerial, and marketing skills must be developed for dietitians to compete effectively. Basic educational preparation and continuing education for practicing professionals must develop these competencies.     

Organisation of ambulatory care by consumers

Abstract This paper deals with how consumers arrange their ambulatory care in a system such as the United States which offers many possible choices. Patters of the different affiliations (sources) that people maintain throughout the year for ambulatory care are formed. The data were obtained in interviews in a sample survey of Rhode Island households conducted in 1974. Although most people in the sample (89.5 per cent) cluster with one to three sources of care, there were over 80 people with four or more affiliations. For those persons with a large number of affiliations, the provider sets become quite varied. Two conceptual typologies are formed, one focusing on type (private physicians versus places) and the other focusing on both the speciality of the physicians involved and the number of different affiliations involved. The United States, at least in theory, maintains a‘free market’health care system. Are there limitations of choice imposed by differential distributions of knowledge, income or age? A wide array of social, demographic, and illness variables were examined to determine their relationship to the patterns. Income has little relationship with the provider set patterns, but persons with a higher education are more likely to report a provider set that includes a primary care specialist (internist or paediatrician), rather than a general practitioner or osteopath. Blacks have different patterns of providers, as do those on Medicaid funding. Thus there is evidence of the continuation of a dual market for health care. The research describes the diversity and complexity of current health care patterns under a loosely structured system of health care such as that found in the United States. While the British health system has traditionally represented a tightly structured system with one path of entry (the general practitioner) into more complex health care services, this may be changing somewhat if current trends in the growth of the private insurance sector in Great Britain continue. Thus the experience of the United States may be of greater policy interest in Britain in the future. There has been a great deal of research in medical sociology and health services research dealing with health behaviour, especially as it relates to ambulatory medical care services. This paper examines how people structure their own health care with the presumably‘free market’system of choice such as operates in the United States. It provides an introductory picture of how people organise services and the variety of sources to which they go to fulfil their medical needs. Berkanovic and Reeder have pointed out that one can study use of medical services through examining the sources from which care Is received or the volume.¹ Much past research has focused on volume of care, emphasising amount of utilisation and number of physicians visits or outpatients visits.^2,3,4,5 The aim of this paper is to analyse sources of care and patterns of ambulatory medical care, not utilisation statistics. An important question is whether there are limitations of choice imposed by differential distribution of social characteristics such as knowledge, income or age. This paper first describes patterns of care-seeking and then relates them to social, demographic and illness variables.     

Emerging trends in gerontology and geriatrics: Implications for the self-care of the elderly

Increases in the world's older population have posed a significant challenge to available health care resources. For many older people, informal initiatives represent a necessary, rather than an optional health care strategy in the absence of alternatives. Those individuals with the greatest health and economic dependencies are often held responsible for their reliance on subsidized long-term care services. This tendency to blame the victim appears to transcend fundamental philosophic differences which have traditionally distinguished some collectivist and individualist societies. Although health care has been viewed traditionally by health professionals as their domain, self-care and lay initiatives have recently been recognized by professionals as important to the health care of different population groups including older people. The concept of self-care has been used in various ways by different people to describe a wide range of personal health behaviors encompassing lay care, self-help, enlightened consumerism, and various preventive measures as antidotes to the impairments of old age. This paper reports some of the outcomes of an international project which reviewed geriatric self-care in different countries and health care systems. Various influences on the evolution of interest in geriatric self-care were identified including: similarities and differences in health care systems: demographic changes; cohort differences; the emergence of professionals with specialized training in geriatric health care; and, the salience of biomedical models in addressing the health problems of aging. The role of professionals, especially those trained in geriatrics, is examined with an acknowledgment of the importance of a self-care strategy that is independent of professional dominance.(ABSTRACT TRUNCATED AT 250 WORDS)